Individual/Runner Name______________________________________________

Address____________________________City_________________

State_____Zip___________Phone__________________Sex_____Age_______

Team name if applicable___________________________________________

Biker Name______________________________________________

Address____________________________City_________________

State_____Zip___________Phone__________________Sex_____Age_______

Swimmer Name______________________________________________

Address____________________________City_________________

State_____Zip___________Phone__________________Sex_____Age_______

I understand that I (and both of my teammates, (if we are on a team entry) will be required to sign an additional acknowledgment-liability form at pre-race packet pickup/registration. An additional signature of a parent or guardian

(in person) will be required for me or any team member 9-18 years of age.

Signature

_____________________________

Shirt Size, ____S ____M ____L ____XL ____XXL

(if team please indicate how many of each size.)

FEES:

$20 Student ( individual age 9-17)

$25 Individual (18+)

$50 Team

Race Day Registration, add $2.00

Make checks payable to Dog Days Triathlon.

To insure a T-shirt, forms must be postmarked

By August 10, 2010.

Print this page and mail with check, to:

Dog Days Triathlon

1725 Union Ave

Belmond, Iowa 50421